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The three hospitals – St Vincent's Hospital (SVH) 440 beds, St ... of Medicine for Elderly, St. Columcille's, St. Vincent's, St. Michael's Hospital and Health.
original paper

Hospital-based stroke care in Ireland: results from one regional register CW Fan, R Mc Donnell1, Z Johnson1, S O’Keeffe, MJ Crowe Department of Medicine for Elderly, St. Columcille’s, St. Vincent’s, St. Michael’s Hospital and Health Information Unit1, Eastern Health Board, Dublin.

Abstract Background Most patients with acute stroke are admitted to hospital. If stroke services in this country are to be improved, we need accurate and reliable information about the types of stroke patients being admitted, their present management and outcome. Aims To examine the demography, severity, level of investigation, length of stay, mortality and discharge location of prospectively identified consecutive stroke admissions to three general hospitals in South East Dublin. Results Three hundred and twenty nine consecutive stroke admissions to three general hospitals in South East Dublin were registered using the European Stroke Database over 50 weeks. The mean age was 73.3 years, whilst 20.1% patients were under 65 years. Prior to admission, 90% of patients were community dwelling with 14.9% of patients being dependent in activities of daily living. 22.4% of patients had some depression in level of consciousness on admission. The overall mortality rate was 26.1% whilst 136 (41.3%) were discharged home, 50 (15.2%) went to institutional care and 45 (13.7%) went to non general hospitals secondary rehabilitation units. The mean length of stay was 31.3 days. The combined poor outcome measure (mortality plus percentage of patients discharged to institutional care), was lower in one hospital compared to the other two hospitals (29.3% versus 44.65%, p≥ 0.05) probably reflecting case mix. Stroke accounted for 4.2% of all bed days in the major general hospital in this area. The overall CT scan rate was 84.5%, with 18.2% of CT scans showing a haemorrhagic component and two patients (0.8%) having brain tumours. Carotid doppler examinations were carried out in 37% of patients. Conclusion The results demonstrate the high mortality and prolonged hospital stay for stroke patients in this area and emphasise the need for co-ordinated stroke care and regular audit to ensure most effective use of hospital resources. (Ir J Med Sci 2000; 169: 30-33)

Introduction With the increasing recognition of the mortality and morbidity associated with cerebrovascular disease, stroke care has been receiving increasing interest. Development of a stroke service requires accurate and reliable information about current patterns of care1. Such information is extremely limited in this country to date. We set out to prospectively examine the types of acute stroke patients being admitted to three general hospitals in South East Dublin, their level of investigation and their outcome.

Materials and methods The three hospitals – St Vincent’s Hospital (SVH) 440 beds, St Michael’s Hospital (SMH) 90 beds and St Columcille’s Hospital (SCH) 140 beds – provide acute general hospital

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services for approximately 320,000 persons in South East Dublin\East Wicklow. Patients were identified between 1st July 1997 and 20th June 1998 by one medically qualified investigator (CF) who attended all three hospitals on a regular basis. Only one of the hospitals (SVH) has an on site computerised tomographic (CT) facility. This hospital also has a stroke team led jointly by a consultant physician in geriatric medicine and a physician in rehabilitation medicine who advise and co-ordinate care of patients over 65 years and under 65 years respectively.2 A geriatric service supervised by a consultant physician in geriatric medicine is present in both other hospitals. Secondary rehabilitation facilities are available in the Royal Hospital, Donnybrook and St Colman’s Hospital, Rathdrum for patients over 65 years from South East Dublin and Wicklow respectively. Selected patients are also transferred to the

National Rehabilitation Centre. The diagnosis of stroke was based on the WHO definition 3 (rapidly developing clinical signs of focal and at times global loss of cerebral function with symptoms lasting greater than 24 hours or leading to death with no apparent cause other than vascular) and was confirmed by history and physical examination. Data were entered on the European Stroke Database4 which consists of a range of data modules dealing with basic demographic information, risk factors, acute care and outcome. Parameters measured included age, sex, level of consciousness, degree of disability one week after admission as defined by the Barthel index5 and use of major diagnostic interventions (CT, carotid doppler studies, echocardiography). The pre-stroke level of handicap was also measured as defined by the Oxford handicap scale5 (modified Rankin Scale where patients in category 0, 1, 2 were independent in self care and patients in category 3, 4, 5 needing varying levels of help with activities of daily living were defined as dependent). Ischaemic strokes were classified on clinical criteria according to the Oxford Community Stroke sub-classification7 as total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), lacunar infarcts (LACI) and posterior circulation infarcts (POCI). Magnetic resonance imaging (MRI) scans were not performed. Outcome data were collected on patient death or discharge from hospital and included length of stay in days and discharge location whether to community, non general hospital secondary rehabilitation unit or institutional care. Data related to predefined complications6 were also collected. The data were analysed in the health information unit of the Eastern Health Board using Epi Info 6.04 software.14 Frequencies and proportions of characteristics of stroke cases were calculated and comparisons by hospital were made using Chi-square tests of significance.

Results

Table 1: Characteristics of stroke patients

SVH

SMH

SCH

TOTAL

p.value

n (%)

n (%)

n (%)

n (%)

Admissions

183

58

88

329

ns

Mean Age (yrs)

72.4

74.4

74.3

73.3

ns

≥ 65 years

143 (78)

48 (82.8)

72 (81.8)

263 (79.9)

< 65 years

40 (21.9)

10 (17.2)

16 (18.2)

66 (20.1)

ns

Male

87 (47.5)

31 (53.4)

39 (44.3)

153 (46.5) ns

Female

96 (52.5)

27 (46.6)

49 (55.7)

176 (53.5)

Independent

157 (85.8)

53 (91.4)

70 (79.5)

280 (85.1)

Dependent

26 (14.2)

5 (8.6)

18 (20.5)

49 (14.9)

Community

173 (94.5)

51 (87.9)

75 (85.2)* 299 (90.9)

Institutional

10 (5.5)

7 (12.1)

13 (14.8)* 30 (9.1)

Pre-Stroke Rankin ns

Living Conditions p